'When you hear hoofbeats, think of horses not zebras' - the old adage is well-known to GPs but what should you do when faced with a zebra, not a horse? Consultant cardiologist Professor Robert Tulloh and GP Dr Louise Tulloh kick off our new series with their advice on how to catch Kawasaki disease in general practice.

Should patients be charged for GP appointments?

23 September 2009

The NHS is facing soaring demand and a squeeze on funding. Charging all but the poorest for appointments could help the health service deliver to everyone who needs it, says Dr Paul Charlson. But the GPC's Dr Chaand Nagpaul warns charging for appointments would be a tax on illness, and might discourage those who most need healthcare from seeing their GP

The NHS is facing soaring demand and a squeeze on funding. Charging all but the poorest for appointments could help the health service deliver to everyone who needs it, says Dr Paul Charlson. But the GPC's Dr Chaand Nagpaul warns charging for appointments would be a tax on illness, and might discourage those who most need healthcare from seeing their GP

The number of primary care consultations is rising inexorably, from 21,204 at a typical practice in 1995 to 29,446 in 2006. Demand is rising at a time when funding is likely to decrease in real terms, with the recession intensifying existing difficulties with NHS funding. When surgeries become busy, consultation time tends to shorten.

It becomes easier to prescribe or refer patients than give lengthy explanations and follow-up. Increased demand, whether appropriate or otherwise, results in inefficient use of NHS services.

So what can be done to stem rising demand? Measures such as educating patients to use services more appropriately have not been dramatically effective. Public health measures encouraging healthy lifestyles may help but will take time and will not necessarily reduce demand for appointments at the primary care level.

A recent report by independent think tank the Social Market Foundation, From Feast to Famine, suggests charging for GP appointments. This idea immediately spreads horror among politicians and the public. My fellow debater Dr Chaand Nagpaul was quoted as saying: 'All patients have a right to free healthcare that is based on their clinical needs not the size of their bank balance.' This sounds fine and noble, but the NHS is not free and those who have larger bank balances already pay more for it in the form of income tax. We also know disadvantaged groups already have poorer access to healthcare.

Charging for GP appointments is simply another tax. Income tax will have to rise over the next few years, so why not have a tax directed at use? It could have the dual purpose of stemming demand and raising revenue. There are many examples of behaviour being changed by small financial incentives and disincentives and this is one possible example. The fees collected could be ploughed back directly into the local health economy, and having to pay for something gives it a feeling of value.

The key to charging is to set a sufficient disincentive to alter consultation-seeking behaviour, without penalising patients to such an extent they cannot afford to see their GP. The Social Market Foundation suggests £20 to see a GP, capped at £100 per year, with those in receipt of tax credits - the poorest 30% - excluded from charges. Retirement or pregnancy would not exempt patients from prescription or GP charges. As David Furness, co-author of the report, said: 'Sir Fred Goodwin should not get free prescriptions when he picks up his pension while working poor people pay for drugs.'

Charges could dissuade people from failing to attend appointments they had booked and might help reduce DNA rates.

Top-ups and co-payments could also be considered. The Government, after pressure from groups such as Doctors for Reform, has already introduced limited top-ups for patients choosing to have additional treatments. If a patient wanted a branded drug that was twice the price of a generic, why should they be denied it if they were prepared to pay the difference?

Charges might also act as an incentive to patients to adopt a healthier lifestyle. Those meeting specific targets in reducing weight or stopping smoking could be offered a reduction in charges, as could those already living healthy lifestyles, or those attending screening appointments.

There are no easy answers but if there is no attempt to reduce demand for primary care, the NHS will fail to deliver where care is most needed. Inequalities will widen.

Introducing charges for GP consultations would be unpalatable but needs serious consideration. We already have NHS charges for prescriptions, ophthalmics and dentistry that are not fair or equitable.

A sensible system of charging should not penalise the poor, but should benefit them, and might help to keep the NHS intact and intrinsically free at the point of use.

Dr Paul Charlson is a GP in Brough, East Yorkshire, and a member of Doctors for Reform. This piece represents his personal views and not necessarily those of any organisation

Those in favour of charging patients to see their GP usually argue that this would manage demand and reduce expenditure in the NHS by dissuading some patients from seeing their GP seemingly inappropriately, and that it would increase revenue to the NHS from those who can afford to pay a fee.

The Social Market Foundation report recommended a charge of £20 per GP consultation, arguing this would make the public 'think about how to ration their own use of precious health resources' and 'encourage healthier, wealthier people to avoid using the NHS except when absolutely necessary'.

But the fact is that the public already pay to see their GP indirectly through taxation, via our nationalised insurance system in the form of the NHS. Charging patients to see their GP would in effect result in the public paying twice to access NHS services. It would become a new tax not on income, but on illness itself, financially penalising patients who needed to see a GP more frequently.

This is the antithesis of the principles on which the NHS was created. Charging patients carries the inevitable risk of paving the way towards a health service only partly funded through taxation, and increasingly reliant on private revenue directly from patients.

An even greater concern is that significant numbers of patients who need medical treatment would not make a GP appointment because of the cost, with the potential for an adverse impact on their health. We know that introducing charges for eye tests in 1989 resulted in a significant reduction in patients attending their optician, with consequently undetected and untreated visual problems. We also know that after the Government reversed this policy in 1999 with free eye tests for the over-60s, there was an increase in the number of pensioners having eye tests. As GPs, we will all have come across patients who have delayed or avoided dental treatment because of the NHS charges.

Nor would charging have any impact on the number of unnecessary appointments, simply because of the significant number who would be exempt, such as children or those on state benefit. The argument for the public to make appropriate and fair use of GP appointments is entirely valid, but this should be addressed separately via national and locally targeted patient and public education.

Crucially, introducing charges would irrevocably damage the time-honoured and unparalleled trust our patients have in us as GPs, as shown repeatedly in patient surveys, even in the midst of adverse media publicity. Fundamental to this trust is the fact that the GP has no financial motive in seeing a patient for a consultation. Patient charges would at a stroke introduce the potential for suspicion in the minds of patients when asked toreattend for follow-up, such as a repeat blood-pressure check.

Furthermore, patient charges would create a new tier of bureaucracy and increase administrative costs. Charges may in fact simply divert patients toward attending A&E or walk-in centres instead, which would increase NHS costs.

The idea of charging to see a GP is anathema to the fundamental ethos of the NHS, based upon flawed and misguided arguments, and would destroy trust between GPs and patients. It would have an adverse impact on the health of some patients, and yet would be unlikely to save costs, while acting as a tax on illness itself.

Dr Chaand Nagpaul is a GP in Stanmore, Middlesex, and a GPC negotiator